Volume 151, Issue 6, Pages 1122-1130 (December 2016) Comparison of Targeted vs Random Biopsies for Surveillance of Ulcerative Colitis- Associated Colorectal Cancer  Toshiaki Watanabe, Yoichi Ajioka, Keiichi Mitsuyama, Kenji Watanabe, Hiroyuki Hanai, Hiroshi Nakase, Reiko Kunisaki, Keiji Matsuda, Ryuichi Iwakiri, Nobuyuki Hida, Shinji Tanaka, Yoshiaki Takeuchi, Kazuo Ohtsuka, Kazunari Murakami, Kiyonori Kobayashi, Yasushi Iwao, Masakazu Nagahori, Bunei Iizuka, Keisuke Hata, Masahiro Igarashi, Ichiro Hirata, Shin-ei Kudo, Takayuki Matsumoto, Fumiaki Ueno, Gen Watanabe, Masahiro Ikegami, Yoko Ito, Koji Oba, Eisuke Inoue, Naoki Tomotsugu, Toru Takebayashi, Kenichi Sugihara, Yasuo Suzuki, Mamoru Watanabe, Toshifumi Hibi  Gastroenterology  Volume 151, Issue 6, Pages 1122-1130 (December 2016) DOI: 10.1053/j.gastro.2016.08.002 Copyright © 2016 AGA Institute Terms and Conditions

Figure 1 Study design. The patients were randomly assigned to either the targeted biopsy group (target group) or the random biopsy group (random group). In the target group, specimens were obtained by a targeted biopsy. In addition, at least 1 biopsy sample was obtained in the lower rectum, even though there were no findings suspicious for neoplasia. In the random group, 4 random biopsies were obtained every 10 cm. In addition, a targeted biopsy was performed from regions suspicious of neoplasia. (A) Two dysplastic lesions were detected by targeted biopsies. A biopsy specimen from the flat elevated lesion on 1 o’clock direction showed high-grade dysplasia, while that from the polypoid lesion in the center revealed low-grade dysplasia. (B) Indigo carmine dye spraying enhanced dysplastic lesions detected by white light endoscopy shown in (A). (C) Areas showing clear vascular patterns without any evidence of present or past inflammation, which could be omitted when performing a random biopsy. (D) Areas with ulcer scars, which may be better surveyed by a random biopsy. Gastroenterology 2016 151, 1122-1130DOI: (10.1053/j.gastro.2016.08.002) Copyright © 2016 AGA Institute Terms and Conditions

Figure 2 The mean number of biopsy samples with neoplasia (A) and the detection rate of patients with neoplasia (B). (A) The mean number of biopsy samples with neoplasia in each surveillance colonoscopy was 0.211 (24 of 114) in the target group and 0.168 (18 of 107) in the random group, thus showing no significant difference (P = .423). Focusing on a targeted biopsy, there was a significant difference between the 2 groups. The target group showed a significantly higher mean number of samples with neoplasia detected by a targeted biopsy than the random group (0.193 vs 0.037; P < .001). (B) The detection rate of patients with neoplasia was 11.4% (13 of 114) and 9.3% (10 of 107) in the target group and random group, respectively, showing no significant difference. A higher percentage of patients had a diagnosis of neoplasia based on the findings of a targeted biopsy in the target group than in the random group (P = .052). Gastroenterology 2016 151, 1122-1130DOI: (10.1053/j.gastro.2016.08.002) Copyright © 2016 AGA Institute Terms and Conditions

Figure 3 Distribution of random biopsied samples with neoplasia. In the random group, all neoplastic samples taken by a random biopsy were obtained from mucosal regions with either history or presence of inflammation. In other words, all random biopsied samples obtained from mucosal regions without history or presence of inflammation were non-neoplasia in the random group. However, in the target group, 1 sample obtained by random biopsy from a mucosa in the rectum without inflammation showed neoplasia. Gastroenterology 2016 151, 1122-1130DOI: (10.1053/j.gastro.2016.08.002) Copyright © 2016 AGA Institute Terms and Conditions

Figure 4 Endoscopic appearances of neoplastic lesions. Neoplastic lesions detected by targeted biopsies. (A, B) A flat granular lesion (0−IIa, low-grade dysplasia) (A: white light; B: indigo carmine dye spraying). (C, D) A coarse nodular lesion (0−IIa, low-grade dysplasia) (C: white light; D: narrow band imaging). (E, F) A flat depressed lesion (0−IIc, low-grade dysplasia) (E: white light; F: indigo carmine dye spraying). Gastroenterology 2016 151, 1122-1130DOI: (10.1053/j.gastro.2016.08.002) Copyright © 2016 AGA Institute Terms and Conditions